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Abstract

Drug testing plays a key role in youth substance use treatment in Sweden. Young people treated for substance use problems are routinely required to leave urine samples, and there is often controversy between patients and staff around its relevance. Still, there is a lack of research on how young people make sense of this practice. This article contributes to this knowledge through an ANT-inspired (Actor Network Theory) analysis of how youth enact urine testing in their treatment experiences. We attempt to tease out what kind of sociomaterial object urine testing is according to youth, and how it affects their lives. The study is based on interviews with 25 previous patients (mean age 17). The analysis shows that the participants enacted urine testing as both a stable object that creates binaries in knowledge networks (use or nonuse), and as a flickering object that appears in and affects diverse drug-body-treatment assemblages (even outside the clinic). The participants had internalized the importance of leaving negative samples to get discharged and avoid adult surveillance. They described a practice that made substance use a demarcated, individual and treatable problem, and also, often contrary to their own self-understandings, devalued their ability to be honest about and regulate their conduct. Through establishing substance use as a simplified either/or phenomenon and through attributing patients with the agency to become nonusers only, urine testing appears counter-productive if treatment is to strengthen informed decision making and responsibility among soon to be adults.

Keywords

drug testing urine samples youth treatment ANT Sweden

Introduction

The web-based FAQ section of Sweden's main provider of youth substance use treatment accentuates the importance of urine testing. It says:

The urine testing result is used as a starting point for your treatment so that you will receive adequate help. If a result is positive on drugs we will talk about the reason for it and whether more support is needed. If you are under 18, we also need to inform parents/caregivers and in some cases social services. (…) Urine tests need to be monitored because we must be able to guarantee that the urine tests are accurate and really belong to you. In this way we can ascertain that we give you the treatment and the support you need. (Maria Ungdom, 2024)

Urine testing, also referred to as urinalysis or more generic drug testing, plays a key role in this youth substance use treatment (Ekendahl et al., 2018), but also in other settings (Schuler et al., 2014). In accordance with Sweden's prohibitionist and abstinence-oriented drug policy (Tham, 2021), all young people who are found using illicit substances such as cannabis are routinely tested. If tests are positive, the most common intervention is a series of counseling sessions combined with substance use assessment and urine testing (Ekendahl et al., 2018; Socialstyrelsen, 2022). Since 1993, the police are authorized to demand blood or urine samples from people suspected of minor drug offence (BRÅ, 2016). Approximately half of the urine samples taken from individuals under age 17 are negative (BRÅ, 2016), and research shows that youth from deprived areas run an increased risk of being tested (Estrada et al., 2022). As there are no clear indicators that use is more prevalent in these areas (BRÅ, 2018), this suggests overuse of drug testing and a tendency to target “membership in the ‘suspect’ classes” (Campbell, 2004, p. 85).

Drug testing may at first glance appear as a technical matter of little interest to social research, similar to taking blood samples or measuring body temperature. Still, from a sociomaterial perspective (Paul & Egbert, 2021) these tests are inscribed with “societal knowledge, hopes and assumptions” that make them appear relevant, trustworthy, and capable of fulfilling concrete tasks (Paul & Egbert, 2016, p. 106). In order to elucidate what societal knowledge is instilled in urine testing, and to discuss how this knowledge affects practice (Fraser, 2020), it is imperative to consider the perspectives of those who are exposed to it (cf. Silvers et al., 2019; Tanner-Smith et al., 2013). This article analyzes youth treatment experiences through the lens of Actor Network Theory (ANT). We analyze how previous patients in interviews enact urine testing as an object in knowledge networks and in drug-body-treatment assemblages (Law & Mol, 2001; Law & Singleton, 2005). Following critical scholarship on how interventions make up the substance use problems they seek to solve (e.g., Fomiatti et al., 2019; Moore & Fraser, 2013; Seear & Fraser, 2014), we also elucidate how urine testing affects how young people make sense of substance use, treatment and their own agency.

Previous Research

Youth in Outpatient Treatment

Municipal social services and regional healthcare share responsibility for the treatment system for both adults and minors with substance use problems in Sweden (SOU, 2021). Minors who are detected using illegal substances (usually cannabis, but sometimes tranquilizers, stimulants, and opioids) or using alcohol in problematic ways are referred to outpatient treatment clinics with healthcare (nurses and doctors) and psychosocial work staff (counselors and case managers). Urine testing is used to determine whether patients have quit or continued using specific substances, which is considered a key outcome in the Swedish prohibitionist context. To our knowledge, there is no publicly available information on what substances are targeted and how often samples are collected at these clinics. The treatment at Maria clinics encompasses counseling, medication, group-based programmes, family therapy, and sometimes referrals to inpatient detoxification units. Stockholm, the capitol of Sweden, has 25 such agencies (called Maria clinics), and they are common in other parts of the country as well (Anderberg & Dahlberg, 2018). They serve minors from 13 to 18 years of age, but young adults up to age 21 are also common. The Maria clinics comprise Sweden's largest specialized caregiver for youth substance use.

The few available studies on youth in Swedish outpatient treatment highlight that the population is heterogenous in terms of backgrounds, difficulties, and needs (Anderberg & Dahlberg, 2014, 2016). As in the general population of young people, quite a large share (up to 50%) of those referred to Maria clinics self-report difficulties such as sleeping problems, anxiety, and concentration problems (Richert et al., 2020). There are pronounced gender differences, with boys being overrepresented in treatment, and girls exhibiting more severe substance use and psychosocial problems (Anderberg & Dahlberg, 2018; Richert et al., 2020). Estimates suggest that slightly more than 75% of those referred to treatment use cannabis, whereas alcohol and other substance use (not separated) is much less common (Anderberg & Dahlberg, 2018).

Studies that focus on how youth perceive treatment show that risk assessments and appeals to taking responsibility are dominating features, regardless of whether patients comply with or resist treatment (Ekendahl & Karlsson, 2022). According to patients, the treatment concentrates on urine testing and conversations that are meant to inoculate the idea of being “at-risk” due to substance use (Ekendahl et al., 2020). Interviews with staff corroborate this picture, but also that the significance of urine testing and surveillance is strategically downplayed in interaction with youth in order to create therapeutic alliance (Ekendahl et al., 2018). Harm reduction approaches that do not aim at abstinence (see e.g., Winer et al., 2022) are not used.

Drug Testing

Drug testing is widely used to detect, monitor, and deter drug use (Wish & Gropper, 1990) in diverse settings such as the criminal justice system (Singleton, 2008), welfare services (Lloyd & Brook, 2019; Wincup, 2014), treatment institutions (Strike & Rufo, 2010), schools (Mears & Knight, 2007; Russell et al., 2005), and workplaces (Phan et al., 2012). The literature highlights various pros and cons of drug testing in detecting substance use and guiding proper responses. Research from the criminal justice system reports that it can be potentially useful to encourage and supervise personal change efforts, but that compulsory testing should be deployed with caution (McSweeney et al., 2008), and be aligned with treatment goals to avoid unnecessary integrity intrusions (Singleton, 2008). As stated by Moore (2011), criminal justice enterprises that aim for behavioral change rather than punishment include both care and control, and these two should be properly balanced to achieve “therapeutic surveillance” (Moore, 2011, p. 257); a benevolent control meant to work in favor of the tested person.

Critical studies, however, suggest that drug tests are employed to govern subjects who use drugs (Campbell, 2004, 2005), and that they often fail as “evidence-producing machines in various fields of practice,” not least due to adulteration of samples (Paul & Egbert, 2016, p. 100). Test results are sometimes interpreted arbitrarily by staff according to specific organizational logics (Paik, 2006; Paul & Egbert, 2016) and can negatively affect goal achievement (Pereira et al., 2020; Sarmiento et al., 2019). Drug testing assumes that people's self-reports cannot be trusted, and that denial of problems is indicative of these very problems (Campbell, 2005, p. 375). Using a technology to scrutinize body fluids means sidestepping supposedly invalid self-reports, and producing allegedly objective data on past substance use. According to Paul and Egbert (2016, p. 107), drug tests are seen as an “impartial replacement for enduring and open-ended negotiations with humans about their (in-)correct judgement.”

As evident in the FAQ section quote above, urine testing of Swedish youth at Maria clinics draws discursively on a mix of care and control and can be described as Moore's (2011, p. 255) “therapeutic surveillance.” While such a technology is often described as attempting to instill self-control and productivity (Campbell, 2004, p. 84), the official rationale considers the identification of substances in bodies necessary for treatment planning and evaluation (Maria Ungdom, 2024). There is, however, a knowledge gap on how the young patients themselves account for this practice, which we address here.

Theoretical Approach

According to a sociomaterial perspective, drug tests are technological devices that produce limited truths about past events (e.g., Aas, 2006; Paul & Egbert, 2016; Sarmiento et al., 2019); they have also been described as “technologies of suspicion” (Campbell, 2004, 2005). The testing is not only a way to collect information about substance use, but also to govern citizens (see e.g., Foucault, 1977; Rose & Miller, 1992). As stated by Aas (2006, p. 144, 154):

Bodies, fused with the latest technologies, are proving to be vital to contemporary governance. (…) The body thus emerges as a source of instant ‘truth’. Surveillance of the body is therefore not simply a question of ‘finding’ information about individuals’ identities; it is also a question of creating identities.

Under the guise of objectivity, drug testing attempts to steer people away from substance use and toward acts and identities that are considered more appropriate (Paul & Egbert, 2016). It “implies the management of population in its depths and its details” (Foucault, 1991, p. 102). Testing becomes a means to direct young people in treatment to attend appointments and counseling sessions, show motivation and engagement, perform in school, find alternative leisure activities and learn to avoid substance use (similar rationales are reported in drug education, see Farrugia, 2023). The urine test becomes key to checking if the patient has been agentic in a good (abstained) or a bad (used substances) way. It both presupposes and denies the tested person's own agency and self-regulation.

Since urine testing is a rather unquestioned pillar of youth substance use treatment (Schuler et al., 2014), it appears able to maintain its function, relevance and “shape” over time and through space (Law & Mol, 2001). Scientific reports about integrity intrusions, adulteration of samples, difficulties with interpreting results and patient/staff controversies around relevance do not seem to affect this practice.

How, then, can we imagine urine testing in accordance with ANT? Law and Mol (2001) suggest that we need to be open-minded about how objects become objects, and how they can move between settings without losing their form or meaning. Law and Mol (2001, p. 609) argue that objects such as technologies have “spatial characteristics” and that they “exist in and help to enact” different “topological forms.” For example, for a scientific fact to become universal, its “heterogenous configuration of people and devices” must be able to move “through regional space while holding its shape” (Law & Mol, 2001, p. 619). Such a scientific fact (e.g., a drug test) does not only appear as a physical object in Euclidean space, but also “implies a stable shape within a network space” (p. 611). In this way, human and nonhuman actants interact in knowledge networks which afford objects to remain stable across settings.

Urine testing at the clinic includes patients, staff, parents, the law, treatment plans, counseling sessions, time tables, secluded spaces, bodies, urine samples, test results, diagnostic systems and, not least, societal knowledge about youth and substances. These are all necessary for it to work as supposed to. Referring to the complexity of such practices, Law and Singleton (2005, p. 337, original emphasis) conclude that “it takes effort to sustain stable networks of relations.” Something would indeed happen with the drug test as an object if this network of human and nonhuman actants were altered, for example by allowing unsupervised urination or more time to pass between tests.

In addition to imagining urine testing as this kind of stable network object, we assume that it can also be more dynamic; a so-called “fire object” (Law & Singleton, 2005, p. 347). According to this reasoning, objects can “achieve constancy by enacting simultaneous absence and presence, a topological possibility which we call here fire” (Law & Mol, 2001, p. 609, original emphasis), and further, that “to make things present is necessarily also, and at the same time, to make them absent” (Law & Singleton, 2005, p. 342). Using the metaphor of the night sky with its flickering “star-like pattern” (Law & Mol, 2001, p. 616), we concretize the notion of fire objects by arguing that the presence of a zodiac sign (i.e., our visualization of it) depends on the temporary absence of unrelated stars and zodiac signs (absent presences). As with stars and zodiac signs, other objects can flicker as well; they are sometimes present and sometimes absent depending on how, when and by whom they are enacted. Law and Singleton (2005, p. 347) discuss why alcohol liver disease should be imagined as this kind of unpredictable fire object:

In this way of thinking, alcoholic liver disease becomes an object that jumps, creatively, destructively and more or less unpredictably, from location to location. It is an object in the form of a dancing and dangerous pattern of discontinuous displacements between locations that are other to (but linked with) each other. (…) This is why, for us, it is a fire object: it lives in and through the juxtaposition of uncontrollable and generative othernesses.

The authors contend that alcohol liver disease is enacted differently across locations, giving rise to different “versions” of the object in different assemblages of problems, patients, therapies, and locations, what we here term drug-body-treatment assemblages. In Law and Singleton's (2005) study, the different versions of alcohol liver disease involve wholly different treatment goals and patients with wholly different characteristics. It ranges from total abstention for those who risk dying, to reduced consumption for those whose alternative would be more harmful use of other drugs. Law and Singleton's main point is that different object versions appear mutually exclusive, but that they are better perceived of as entailing each other; all versions are both absent and present at the same time (e.g., alcoholic liver disease can be both deadly and the lesser of two evils). This way of imagining objects encourages us to examine what absences and presences different enactments result in. In the case of urine testing, we can assume that youth treatment experiences encompass different versions of it (e.g., it can both increase and decrease motivation to quit substance use). It is therefore important to ask what aspects of youth lives these different versions highlight and obscure.

Data and Methods

The study is based on 25 qualitative interviews with youth who had been enrolled at Maria clinics sometime during the past two years. A letter with information about the research and invitation to participate was sent to 100 randomly selected patients aged 15 to 20 years in the Stockholm region. To achieve a sufficient sample size, this procedure was iterated in three rounds during February to May 2023.

The sample consists of 12 girls and 13 boys, with a mean age of 17, who all provided written informed consent to participate. Their clinical experiences varied from substance use assessment during a couple of months to counseling and treatment over several years. At the time of the interview, most of them were still in treatment or about to be discharged. Their substance use varied from occasional cannabis use to frequent use of for example tranquilizers, stimulants, or alcohol. While participants were randomly approached to take part, the sample is self-selected, with individuals probably choosing to participate because they considered their story worth sharing. Their socioeconomic status was not addressed, but some mentioned troubled upbringings including referrals to out-of-home care, while most emphasized being raised in “good” families. A majority mentioned own struggles with mental health, such as depression, anxiety, neuropsychiatric disorders, or trauma.

The interviews were carried out by the second author in places chosen by the participants, either at the university (10), digitally (1) or over the phone (14), with an average duration of 41 min. The interviews were semistructured, starting with questions about the circumstances leading up to referral, over into prior treatment experiences and concluding with treatment discharge and future expectations. The interviews were audio-recorded and transcribed verbatim. Extracts have been translated from Swedish to English by us.

The study was approved by The Swedish Ethical Review Authority (2022-02494). Since the participants were all minimum 15 years old, Swedish legislation does not demand parental consent, which was not collected. The participants were pseudonymized with aliases and sensitive information was omitted. The Maria clinics represent the main youth treatment organization in Sweden and have not been pseudonymized.

The analysis was commenced with a content-based coding of the full material where all accounts of urine testing were singled out. These were then inductively coded into different views on what urine testing feels like, what it does and with what perceived effects. After this we employed an ANT-understanding (Law & Mol, 2001; Law & Singleton, 2005) to differentiate accounts that enacted it as a stable object that produces “truths” in knowledge networks from accounts that enacted it as a flickering object that appears in diverse drug-body-treatment assemblages and makes other aspects of youth lives either absent or present. The results below are structured according to these two enactments.

Urine Testing Generates “Truths”

Previous research shows that people's opinions on urine testing differ depending on context and the aims of its use (McSweeney et al., 2008; Strike & Rufo, 2010). Corresponding with this, our participants felt that urine testing was integrity intrusive, stigmatizing and time-consuming, but also an unproblematic routine, a motivational boost and evidence of recovery. Instead of discussing such experiences further, we will go into more detail on how it is stabilized as a spatially demarcated practice that generates “truths” about being “clean” in knowledge networks.

Being “Clean” While Using

Regardless of age, gender, ethnicity, substance use, health status or psychosocial situation, participants talked about urine testing as part and parcel of treatment. The typical procedure was to come once a week, enter a secluded space, urinate while being monitored and then have a short conversation with staff about substance use, treatment progress, and everyday life. In this version, urine testing provides valid, objective information about past behavior that can circulate in networks to calibrate treatment responses (e.g., increase/decrease the intensity of testing, prolong/cut treatment, target detected substances in counseling sessions). The testing determines if the patient is “clean” or not and as such stabilizes behavior and identities.

This concrete form of biopower regulates people through objective scrutiny and control of their bodies (Aas, 2006; Campbell, 2004; Foucault, 1977; Rose & Miller, 1992) and reinforces that drug use and drug users are binary phenomena. The test results create points of reference that all actors in the knowledge network have to consider when interacting with the patient.

Imagined as a network object, the meaning and function of urine testing remain stable when moved between locations. A positive test establishes a “drug problem” no matter when, where or by whom the test is interpreted. Accordingly, which was also mentioned by some participants, patients could be referred to urinalysis at any Maria clinic without this affecting test results or test validity (cf. Paik, 2006; Paul & Egbert, 2016). Urine testing produces universal effects on the reality that the actors of the network are faced with; either one of nonuse and treatment success or one of continued substance use and treatment failure. As the participants claimed that they sometimes tamper with urine tests or use substances in ways that decrease risk of detection (see below), the concurrent reliance on test validity in the knowledge network creates different realities that exist side by side. In one reality, the patient makes progress through sobriety and in another this is a mere front that covers ongoing substance use. Both realities are made possible through the enactment of urinalysis as a network object. The participants’ accounts suggest that as long as the tampering remains undetected, test validity is never questioned.

In the following extract, Sofia (age 18), who has mainly used cannabis and describes herself as “having been addicted,” explains the emphasis placed in treatment on negative urine tests in determining her needs. She states that contact with the Maria clinic has contributed to “personal development” and that she has learnt that cannabis use worsens rather than solves her problems. Sofia expresses gratitude for having met qualified treatment staff, but explains that, during the first out of several successive contact periods with the Maria clinic, it felt necessary to combine cannabis use with treatment, which was achieved through “pee tampering.” She claims to have deployed this trick until discharge, illustrating that she during several months enacted a reality of nonuse in the knowledge network of treatment and a reality of use in her daily life. When assessing this behavior in hindsight she mentions a gradual development of addiction problems (e.g., tolerance, increased use, and polydrug use) and concludes that it did not serve her well.

Sofia: I remember getting caught by the police because I had been smoking [cannabis] and I dropped dirty on benzos, tramadol and cannabis, and it was a shock to my whole family because I’d quit drug testing six months before, had been clean for a long time, and then from out of nowhere everything was even worse. Basically, it only got worse and worse and it was a real struggle back then because eventually, you only felt worse and worse and worse.

I: Ok, I see. So, when you terminated the contact with the Maria clinic, was that because you had become clean, and then you started again?

Sofia: No, I was at the Maria clinic the first round, couldn’t quit [cannabis] and then tampered my pee so they believed I was clean, but I wasn’t clean. And then, through this, I managed to quit [treatment], I could show that I was clean for eight months through cheating, and eventually I was discharged. And under these circumstances everything got worse and worse because I knew that I could get away with anything. But it was later when I was caught, after being discharged [the first time]. Then it got worse and worse and six months later I was caught by the police. Because of getting detected I got another round of drug testing.

Being believed to be “clean” by treatment staff and family, Sofia managed to keep her substance use undetected. She describes an ongoing process of “managing to quit” treatment but at the same time using more substances than cannabis. When getting caught by the police after discharge from the Maria clinic, the restart of urine testing detects not only cannabis but also opioids and tranquilizers. In this case, urine testing produced a “truth” in which Sofia was a nonuser. This “truth” spread in the knowledge network and obscured her feelings of distress and a deteriorated psychosocial situation.

Zero-Tolerance Toward Cannabis

Some participants also discuss urine testing as a potential door opener to desired treatment possibilities, such as medication or specialized therapies. Dan (age 18) who had occasionally smoked cannabis, explains that he must go through drug testing to receive stimulant treatment for ADHD: “Yes, to get medication I have to continue leaving samples because they don’t want to hand out medication if I’m positive on anything. I’m still in contact with them.” Here, urine testing as a network object produces the binary result of nonuse. The absence of an illegal substance makes possible the prescription of a legal one, which emphasizes the difference between “threatening” drugs and “beneficial” medicines (Herschinger, 2015, p. 183). Dan explains that he has provided negative samples for months. However, at the time of the interview, this does not serve as sufficient “proof” for him to become a nonuser in the knowledge network. Hence, he has to continue testing for an unknown period of time to receive the medication he wants. Dan, on his part, never pictured himself as a substance user in need of help and resisted treatment throughout the whole process. Initially, he contested the staff's characterization of cannabis as utterly dangerous, but realized that this only resulted in him being even more monitored and controlled (cf. Ekendahl et al., 2018; Ekendahl et al., 2020). Dan also mentions that being compelled to quit smoking cannabis, rather than getting the chance to reach this decision on his own, made him even more disobedient.

I: So, did you end up smoking even more back then?

Dan: No, not really, it was more like me doing it timely, straight after testing, like that, and I probably wouldn’t have done it if they hadn’t triggered me. So, I was like, ah come on.

I: I see. Did you also end up using other drugs, that wouldn’t show up on the tests?

Dan: Well, I thought about it, but it didn’t happen, I rather started to drink [alcohol] a bit more because I knew they wouldn’t care about that, which I thought was somewhat hypocritical, some substances are ok but some aren’t, even if both have negative consequences.

The account depicts yet another example of how participants claim to use substances strategically to enjoy the benefits of being “clean” while using. It also indicates that only certain substances are of interest to the staff, which Dan himself finds “hypocritical.” Alcohol does not belong in the knowledge network depicted here and does not reproduce the binary of user and nonuser. The urine testing is limited to the initial problem, which in Dan's case was cannabis use. In this way, a circumscribed “truth” is created, in which cannabis is the only point of reference. Urine testing as a network object enacts the patient's substance use problem as easily identifiable and treatable in a straightforward manner.

Urine Testing Appears Outside the Clinic

In this section we imagine urine testing as a fire object that produces patterns of absent presence, rather than stability and predictability (Law & Singleton, 2005). We shift focus from it being an object intertwined with the knowledge network of treatment, to the effects it has on drug-body-treatment assemblages in other locations.

Drug Use as Active Decision Making

As illustrated above, the presence of urine testing warrants a choice for the patients between opposition and compliance. Before treatment referral, substance use should have been one out of several other activities that the youth could engage in; the opportunity to take drugs was sometimes present and sometimes absent. When faced with urine testing, however, the decision to either use or not use becomes always present. Even if the patients feel incapable of making this choice, and even if treatment transforms substance use into a (sometimes distant) past experience, choosing “right” or “wrong” becomes the defining characteristic of their treatment engagement. Through its high stake, the decision becomes present in its absence as well.

Those who choose opposition are faced with consequences if caught cheating, which makes using other substances than those initially targeted by testing a suitable alternative. Substances that were previously absent thus becomes present in their lives. As Marcus (age 16), who was caught with cannabis use, says: “If not for the Maria clinic, I wouldn’t have tried ecstasy, wouldn’t have tried LSD, wouldn’t have tried benzodiazepines or tramadol or any of these drugs.” Substance use as opposition can also result in more surveillance (increased testing frequency) which in turn creates unpleasant feelings and accentuates that the treatment concerns “substance abuse” (Sigrid age 17).

Those who choose to comply talk about a new situation in which substance use becomes strenuous or impossible. Urine testing appears in drug-body-treatment assemblages outside of the Maria clinic as a reminder that they have problems. It enacts substance use as a taboo activity that is always present, even in its absence. Jessica (age 17), for instance, has used benzodiazepines and talks about how everything turns “incredibly difficult” when urine samples are positive. The test result transports from the clinic to her relationships with family and friends who all, in an instant, can become “really sad and disappointed.” For Jessica, as for other participants, living with this constant risk of making others upset by diverging from the “ideal of abstinence” (Campbell, 2004, p. 83) converts external pressure into internal motivation. As she says: “It's all good, because at first, I can’t be bothered doing it [using drugs], and then from not being bothered, it somehow turns more into me not wanting.”

“Problematic” Drug Using Events

The capacity of urine testing to be present outside the clinic renders future substance use a concrete reality that needs to be handled, more than an abstract potential. Jessica's vigilance in avoiding it illustrates how events that have not occurred can have behavioral effects as absent presences (Law & Singleton, 2005). She also discusses how positive test results can have bearing on past events; how urine testing appears in and problematizes prior experiences of substance use.

I: And then there has been a lot of these ‘frustrating meetings’, can you exemplify, what happens during one of those ‘frustrating meetings’ after a positive urine test?

Jessica: Well [sigh] I don’t know, they [staff] sort of ‘What was that about, really?’, and I go: ‘I don’t know!’, that's what you kind of say: ‘I don’t know’. And then you have to sort of explain what's going on [during substance use]. And clearly, you sort of don’t really know why, so you have to explain other people's [substance using friends] thoughts and what happened during a specific event, what went on, and usually something bad didn’t even happen. I don’t know, it kind of gets, I don’t know, you tend to feel worse afterwards, because of all the frustrating stuff.

This shows how substance use is enacted in counseling in a way that does not correspond with Jessica's own understanding. In treatment, she is encouraged to problematize and “explain” what went on during an occasion of use, which she finds difficult and misplaced because “something bad didn’t even happen.” Urine testing makes present a drug-body-treatment assemblage in which substance use is inherently problematic. It is unfitting with adequate progress and possible to explain through ex post facto deliberation, or as Rennerskog (2023, p. 13) claims: “the problem, as well as the solution, starts with the child.” It also obscures positive experiences of substance use (see e.g., Farrugia, 2015) and establishes that any incidence of use indicates clinical relapse (see e.g., Buckheit et al., 2018).

Circumscribed Youth Agency

Jessica exemplifies how urine testing through continuous monitoring demands rationality and agency of youth, while at the same time allocating control to adults. Actors such as district attorneys, social service case managers, treatment staff and sometimes parents decide the length, form and content of treatment. This drug-body-treatment assemblage assumes the presence of a young victim of addiction who cannot be trusted and cannot determine what interventions are relevant. Marcus (age 16) illustrates this point further. He is dissatisfied with the Maria clinic, wants out and claims that urine testing makes it impossible to taper down cannabis use, which he prefers.

I: This with providing negative samples, you don’t know if it will work?

Marcus: Exactly, because it's kind of, it's hard to quit smoking [cannabis], at least the first few days. But it's kind of hard to keep from it a month, and now, as I left a positive sample it will probably be more than a month, maybe five weeks or so. Because, if I were to force myself to quit smoking, I’d taper down sort of. From smoking almost every day, to once every third day, or once a week, once every two weeks, to once a month. And then quit altogether. It's very difficult to quit all at once when you’ve been smoking like every day.

Here, urine testing disrupts the patient's ability to find a personalized path to recovery (in Marcus’ case: to produce a series of negative samples to get discharged). The generation of binaries through urinalysis shown above (user/nonuser) is made present in the everyday life in which Marcus is to quit cannabis use. He finds it difficult to be abruptly forced to abstention, has ideas about how this could be achieved through other means, and fails to provide negative tests which prolongs the surveillance he is exposed to. For a worried adult world, it might be better for Marcus to stay away from cannabis altogether, which also explains the lack of harm reduction approaches in this setting. Still, his interview illustrates that urine testing negatively affects the aspect of his life that the treatment targets: his ability to avoid cannabis through self-regulation. If the intervention aims to help Marcus in strengthening his self-efficacy, it appears counterproductive (Pereira et al., 2020; Sarmiento et al., 2019). Hence, urine testing can simultaneously make present and absent the agency and control of youth. Its effects flicker.

Living Conditions Downplayed

As a final example, we turn to Viktor (age 16) who has a history of cannabis use and several previous referrals to both the Maria clinic and out-of-home care, including extensive contact with social services. Viktor has grown up in an environment where illegal substances are common and he has used cannabis to cope with “family problems, serious stress and no sleep.” He is pleased with the Maria clinic staff, because it has supported him “to improve” on his own terms. Viktor explains how he managed to quit cannabis use: “I just hung out with better people, exercised hard as hell, struggled with school and my family, anything I needed to do, I did it.”

Viktor's interview clearly illustrates how youth are made responsible in treatment (Ekendahl et al., 2020; Rennerskog, 2023). While facing several challenges in his surroundings (related to neighborhood, family, school, mental health, etc.), he insists on having the solution in his own hands. The presence of this individual responsibility also de-responsibilises governments, authorities and living conditions, making them absent in this drug-body-treatment assemblage. In Viktor's experience, it is the social services rather than the Maria clinic that demands abstention. Below, he expands on how external pressure to leave negative samples can increase anxiety.

Viktor: Like this, ‘you have to be negative this Tuesday, otherwise we will send you away’ [to a foster home]. I’d be really stressed out in a situation like that. They [patients exposed to this] will only get angry at those who decided it. What I think would be of more help to youth, is to stop putting them in situations where they must struggle, and then maybe put them in situations where they feel they have to work on life instead. I know people, and the social services have told them that you should quit smoking [cannabis], and then they say that when you quit smoking you will begin to feel good again, because it's bad for you. And when they return from treatment they feel really bad, because they feel like they [social services] did not focus on me. All they wanted was to get rid of the problem, as if it was a parasite in a fish sort of. They just wanted it gone, without thinking about the harms that come later.

This account elucidates how urine testing intertwines with and makes present Swedish abstinence-oriented drug policy (Tham, 2021). Viktor also associates positive test results with being involuntarily placed somewhere else. He argues that narrowly concentrating on quitting cannabis use obscures generic life problems and the costs that treated individuals experience being pushed to sobriety. In his principal discussion about how the system can best help youth, urine testing is a key actant in a dysfunctional drug-body-treatment assemblage. It makes present the cannabis use that other people consider of topmost importance (“a parasite in a fish”), which authorizes the power of those “who wanted it gone.” Viktor's freedom to act all depends on his ability to say no to drugs.

Discussion

Imagined as both a network object and a fire object (Law & Mol, 2001; Law & Singleton, 2005), urine testing registers binary “truths” about substance use in the knowledge network of the Maria clinic, and appears in diverse drug-body-treatment assemblages that affect youth in multiple ways. Its omnipresence in treatment trajectories, and its reliance on technology as an “impartial replacement for enduring and open-ended negotiations with humans” (Paul & Egbert, 2016, p. 107), makes several aspects of youth lives sometimes absent and sometimes present. While urine testing is portrayed by the Maria clinics as necessary for adequate treatment, it has additional effects on youth lives. The participants talked about how the goal of leaving a series of negative urine samples could obscure aspects such as: substance use that remains undetected through pee tampering (Sofia, Dan); the meaning or lack of meaning attributed to substance use (Jessica); personalized methods employed to modify behavior (Marcus); and structural conditions that can produce the very problems that treatment aims to remedy (Viktor). Urine testing also made present a demarcated and treatable drug problem (Dan, Viktor), the potential of using drugs not targeted by testing (Marcus), the fear of relapsing and making others disappointed (Jessica) and the abstinence-orientation of Swedish drug policy (Viktor).

Our analysis also suggests that urine testing reduces the participants’ incentives to be honest about and find ways to self-regulate behavior. The centrality of negative test results in treatment affirms that the young patients are only attributed with the agency to demonstrate that they are “clean,” which iterates the tendency in youth drug education “to produce compliant rather than autonomous subjects” (Farrugia, 2023, p. 1).

While urine testing may temporarily push young people towards acts and identities that are considered more appropriate than substance use (Paul & Egbert, 2016), its explicit and detailed “management of population” (Foucault, 1991, p. 102) reproduces them as “responsibilized becomings” who are as of yet incapable of governing themselves, rather than as “responsible beings” in their own right (Rennerskog, 2023, p. 13, our emphasis). It therefore appears contradictory to give drug testing such a key role in the responsibilization of youth, which is often identified as the main objective of treatment (Ekendahl et al., 2018; Rennerskog, 2023). The elongated process of making patients leave urine samples under surveillance presumes that they cannot be trusted to report accurately on their own behavior and are persons in need of external control. In this way they are made up as deficient vessels of a developing responsibility.

As youth substance use can include positive experiences such as sociality and play (Farrugia, 2015), it would be reductionistic to reject it as always problematic and worrisome. From this perspective, we are not surprised that some participants claimed to use drugs in a timely manner to avoid detection or cheat in other ways. While this is clearly problematic in an abstinence-oriented, prohibitionist policy context, it also reflects a situation where users are afraid of being honest as they risk being sanctioned and stigmatized. To not miss out on the potential benefits of urine testing in facilitating behavior change (Moore, 2011; Strike & Rufo, 2010), but to avoid the negative side-effects outlined in this article, the intervention should be offered voluntarily. The current routinized collection and scrutiny of body fluids reinforce a myopic and binary view on drugs as the core problem in young people's lives. We therefore believe that youth substance use problems are better solved with harm reduction than with zero-tolerance approaches.

A limitation of this study is its lack of staff perspectives. Still, previous research corroborates the weight placed on urine testing in Swedish treatment for youth substance use (Ekendahl et al., 2018; Ekendahl et al., 2020). As a final note we argue that the treatment system's naïve reliance on and use of this technological device makes visible youth substance use at the cost of obscuring the societal knowledge it is inscribed with (Paul & Egbert, 2021). Rather than informing future patients about “therapeutic surveillance” (Moore, 2011, p. 255), the web-based FAQ section referred to in the introduction ought to state clearly that urine testing seeks the truth in technology rather than in humans, that people must submit to its demands on rationality, healthy living and control, and that detected substances will always be considered problematic. If caregivers disseminated this societal knowledge at the onset of treatment, their responsibilization of next generation's substance users would be more visible and honest.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The work was funded by Forte (grant number 2021-01726).

ORCID iDs

Mats Ekendahl

Petra Kvarmans

Author Biographies

Mats Ekendahl (PhD, professor) is a researcher and lecturer at the Department of Social Work at Stockholm University. His main research interest is in user perspectives, substance use, treatment, drug policy and drug discourse.

Petra Kvarmans (master's degree in social work) is a research assistant at the Department of Social Work at Stockholm University.

Patrik Karlsson (PhD, professor) is a researcher and lecturer at the Department of Social Work at Stockholm University. His research covers a broad range of issues related to substance use, including epidemiology, treatment, and prevention.

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Urine Samples and Drug-Body-Treatment Assemblages: Youth Enactments of Drug Testing in Sweden

Abstract

Keywords

Introduction

Previous Research

Youth in Outpatient Treatment

Drug Testing

Theoretical Approach

Data and Methods

Urine Testing Generates “Truths”

Being “Clean” While Using

Zero-Tolerance Toward Cannabis

Urine Testing Appears Outside the Clinic

Drug Use as Active Decision Making

“Problematic” Drug Using Events

Circumscribed Youth Agency

Living Conditions Downplayed

Discussion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iDs

Author Biographies

References